prezentare rolul ultrasonografiei Doppler in evaluarea arterelor carotide

1. ULTRASONOGRAFIA
CAROTIDIANA
Alexandru Andritoiu, MD
Sp. Militar Clinic de Urgenta Craiova
ESC, EAS, Artery Research

2. Sistemul carotidian
(extra-cranian)
(A)
(B)

3. Variante geometrice
ale bifurcatiei carotidiene

4. Poligonul Willis

5. Henri Marie Coanda
(1886–1972)
,,Coanda effect or wall-attachment
effect (1930) - the tendency of a moving
fluid, either liquid or gas, to attach itself to
a surface and flow along it,,

6. Principiul Bernoulli


In fluid dynamics, Bernoulli's
principle states that for a flow, an increase in
the speed of the fluid occurs simultaneously
with a decrease in pressure or a decrease in
the fluid's potential energy.
Bernoulli's principle is named after the DutchSwiss mathematician Daniel Bernoulli who
published his principle in his
book Hydrodynamica in 1738.

7. Tehnici de examinare
US






ANATOMICE
B-mod
Panoramica
3D
IVUS
CEUS







HEMODINAMICE
B-flow
Sie-flow
Doppler spectral
Angio
CEUS
TDI

8. Set ari







B- m od
Gaine
DGC
Depth
Power
Dynamic range
Focus









DOPPLER
PRF (mean-high)
Color-box
Steer
Base-line
Syncrone
Gate
Scale
Angle < 60 gr

9. B-mod
Sectiune in axul lung
Sectiune in ax transversal

10. Doppler spectral
ACC
ACI
ACE

11. Indicii spectrali

12. Valorile de referinta ale parametrilor Doppler spectral
pentru segmentul extracranian al arterelor carotide
ACC
ACI
proximala
ACI
distala
Vmax S (cm/s)
59
57
65
Vmin D (cm/s)
15
22
27
Legenda: Analiza a fost efectuata pe un lot de subiecti
potriviti ca varsta si sex:
21-40 ani (N=46), 41-60 (N=56), >60 ani (N=56).
Pentru sexul feminin s-au remarcat valori mai mari ale
velocitatilor in ACI, dar nu si in ACC.
Andritoiu A 2009

13. IR - Varsta
IR
0,85
0,8
0,72
0,72
0,74
0,76
0,79
0,75
0,7
0,65
0,6
40-49 50-59 60-69 70-79 80-89
Ani
N = 405; varsta 40-90 ani
Andritoiu A 2009

14. Diametrul ACC (mm)
Diametrul carotidian
7
6
5
4
3
6,37
5,89
B
F
2
1
Diametrul mediu al ACC masurat la un lot de 405 subiecti
cu varsta intre 40-85 ani (237 B si 168 F)
Diametrul mediu in grupul barbatilor a fost de 6.37+/-0.7 mm, iar in cel al femeilor de
5.89+/-0.6 mm (p<0.01). Varsta medie a celor doua grupuri nu a fost diferita statistic.
Andritoiu A 2009

15. Fenotipuri arteriale
(1) diametrul si grosimea medio-intimala normale,
(2) ingrosare izolata a complexului intima-medie,
(3) cresterea izolata a diametrului arterial,
(4) cresterea in dimensiuni atat a diametrului cat si a
complexului intima-medie.
Eigenbrodt ML 2008

16. Relatia D – Frecv. Placi ATS
75
% Placilor
80
58
60
40
38
25
23
4-4,9
5-5,9
20
0
6-6,9
7-7,9
8-8,9
Diam etrul ACC (m m )
Rezultate obtinute prin evaluarea ultrasonografica a unui lot de 405
subiecti cu varsta cuprinsa intre 40-85 ani.
Andritoiu A 2009

17. CIMT

18. CIMT

19. .
Relatia CIMT - mean wall shear stress
(relatie directa)
Carallo C et al. Hypertension 1999;34:217-221

20. .
Relatia CIMT - mean circumferential wall tension
(relatie inversa)
Carallo C et al. Hypertension 1999;34:217-221

21. CIMT


VN <0.9 mm
Masuratori manuale
Masuratori automate

22. Masurarea CIMT prin ecografie in mod B
Exemplu de la un subiect din studiul METEOR
Imagine ecografica a arterei carotide
Detaliu aratand masurarea CIMT

23. CIMT - CEUS

24. CIMT –Marker de risc CV






Scorul de risc (Framingham,
SCORE)
Boala coronariana ischemica
Sdr. metabolic
Arteriopatia obliteranta
Disfunctia endoteliala (%FMD)
Markerii de inflamatie (hs CRP)



Studiul ARIC
Studiul
Rotterdam
Cardiovascular
Health Study

25. Volume 340:14-22
January 7, 1999
Number 1
Carotid-Artery Intima and Media Thickness as a Risk Factor for
Myocardial Infarction and Stroke in Older Adults
Daniel H. O'Leary, M.D., Joseph F. Polak, M.D., M.P.H., Richard A. Kronmal,
Ph.D., Teri A. Manolio, M.D., M.H.S., Gregory L. Burke, M.D., M.S., Sidney K.
Wolfson, M.D., for The Cardiovascular Health Study Collaborative
Research Group
Incidence of Myocardial
Infarction or Stroke According
to Quintile of Carotid-Artery
Intima–Media Thickness.

26. IMT in subjects with and without clinical
atherosclerosis.
Hashimoto M et al. Arteriosclerosis, Thrombosis, and Vascular Biology. 1999

27. CIMT – genetica HDL

28. Relatia CIMT - varsta
CIM (mm)
0,8
0,6
0,4
0,2
0
40-49
50-59
60-69
70-79
80-89
Ani
N = 405 subiecti; varsta 40-90ani
Andritoiu A 2009

29. CIMT sex M > CIMT sex
F
0,54
p<0.01
CIM (mm)
0,52
0,5
0,48
0,46
0,44
0,42
B
F
N = 405 subiecti; 237 B – 168 F
varsta 40-90 ani
Andritoiu A 2009

30. Relatia dintre grosimea
CIM
si prezenta placilor ATS
0,8
0,63
0,44
0,6
0,4
0,2
0
Placa
Non-Placa
r = 0.40; p<0.0001; IC95% 0.281-0.514
N = 405 subiecti; varsta 40-90 ani
Andritoiu A 2009

31. Influenta CIM asupra IR este
semnificativa statistic
r = 0.21, p = 0.03
( IC 95% ; 0.073-0.338)
Andritoiu A 2009

32. PLACA DE ATEROM

33. Prevalenta placilor
carotidiene
Pac. fara
placa;
780; 60%
Pacienti cu
placa;
515; 40%
N = 1295 subiecti; 40-90 ani; B 720: F 575
Andritoiu A, nepubl.

34. Prevalenta placilor ATS
pe decade de varsta
Prevalenta %
100
81,25
80
60
40
20
43,8
57,14
28,35
13,79
0
40-49 50-59 60-69 70-79 80-89
Ani
N =405; 40-90 ani
Andritoiu A 2009

35. Aspecte

Placi nodulare

Placi parietale

36. Placa ,,in musuroi,,

38. Aria placii de aterom

39. Volumul placii

Reconstructie 3D

40. Ecogenitatea





Anecogena
Hipoecogena
Ecogena
Hiperecogena
Hiperecogena cu con de umbra (Ca++)
REPERE
• Lumenul vascular
• Mm SCM
• Adventicea (apofiza traversa)

41. Placa vulnerabila

42. Placa instabila (,,la
risc,,)




Capison subtire
Suprafata ulcerata
Miez lipidic
Hipo/anecogena

43. Analiza histografica a
placii

44. Reconstructie 3D
distributia Gray-scale value

45. Elastografia placii?
NU! Doar Adobe Photoshop!!!!

46. Mapping color
( Adobe Photoshop )
Adobe Photoshop – Gradient Map
ROI - Gradient Map

47. Relation between plaque characteristics
and primary outcome.
Hellings W E et al. Circulation 2010;121:1941-1950

48. Mecanismele
neoangiogenezei

49. Neovascularizatia placii
Feinstein SB - JACC 2006

50. Neovascularizatia placii
-CEUS
Staub D - Stroke 2010

51. Vessel Density at Histology According to Plaque
Contrast-Agent Enhancement
Coli S. et al. J Am Coll Cardiol 2008;52:223-230

52. Hypoechoic Carotid Plaque With Extensive (Grade
2) Contrast-Agent Enhancement
Coli S. et al. J Am Coll Cardiol 2008;52:223-230

53. Relatia dintre
neovascularizatie si
instabilitatea placii
Matsumoto N 2010

54. Plaque Without Contrast-Agent Enhancement
Showing Scant Neovascularization at Histology
Coli S. et al. J Am Coll Cardiol 2008;52:223-230

55. Plaque With Grade 2 Contrast-Agent
Enhancement Showing Abundant
Neovascularization at Histology
Coli S. et al. J Am Coll Cardiol 2008;52:223-230

56. Grade of Contrast-Agent Enhancement According
to Plaque Echogenicity
Coli S. et al. J Am Coll Cardiol 2008;52:223-230

57. Neovascularizatia placii
si riscul C-V
Staub D - Stroke 2010

58. Placa ulcerata

59. CEUS – ulceratia placii
Feinstein SB - JACC 2006

60. STENOZA
CAROTIDIANA

61. Prevalenta stenozei si
ocluziei carotidiene
1.15/1000
0.46/1000
15
6
st enoza
ocluzie
N = 1295 subiecti; 40-90 ani; B 720: F 575
Andritoiu A, nepubl.

62. Calculul st enozei
( angiograf ic )
d
NASCET vs ECST vs CC

63. Calculul angiografic al
stenozei carotidiene

64. NASCET vs ESCT
Metoda americana
(NASCET, ACAS)
Metoda europeana
ESCT
30%
40%
50%
60%
70%
80%
90%
65%
70%
75%
80%
85%
91%
97%

66. Stenoza ACI - Doppler
color

67. METODELE
PLANIMETRICE
%D
%A

68. METODELE
VELOCIMETRICE
PSV(cm/s)
EDV (cm/s)
PSV ACI/PSV
ACC
<150
<50
<1.8
50-70
150-250
50-90
1.8-2.8
70-90
250-400
90-150
2.8-5
90-99
>400
>150
>5
% Stenozei
<50

69. Relatia MeanV Ratio-Angiografie

70. 3D Power-angio
Wessels T- Stroke 2004

71. Stenoza severa (asimptomatica) de ACI la un pacient in varsta de
68 ani. Examinarea Doppler color evidentiaza flux stenotic, cu aliasing
color. Planimetric (%D), stenoza este apreciata la 77% - metoda
europeana ESCT. Diametrul lumenului stenozei este de aproximativ 1.5
mm. Examinarea power-angio evidentiaza tendinta de stenoza
preocluziva, cu efilarea zonei de culoare. In modul spectral, PSV este
estimata la 260 cm/s.

72. Cuant if icarea st enozei
carot idiene prin I VUS

73. Ghiduri

2003-The
Radiologists
Consensus
Society
of
in
Ultrasound

2008- Joint Recommendation for
Reporting Carotid Ultrasound
Investigations in the United
Kingdom

74. Gradarea US a stenozei
ACI
Gradul stenozei
(%)
PSV ACI
(cm/s)
Raport PSV
Normal
<125
<2
<50
<125
<2
50-69
125-230
2-4
>70-90
>230
>4
Variabil
Variabil
Nedetectabil
Nedetectabil
Preocluzie
Ocluzie
Society of Radiologists in Ultrasound; Grant EG et al- Radiology 2003;229:340-346)

75. Dr. Eugene Strandness
University of Washington






Normal = no plaque, no turbulence PSV <125 cm/sec
1-15 % stenosis = minimal plaque, PSV < 125 cm/sec
16-49 % stenosis = moderate plaque, mild spectral
broadening throughout systole, PSV < 125 cm/second
50-79 % stenosis = PSV > 125 cm/second, greater spectral
broadening throughout systole, heavier, more prominent plaque
formation present.
80-99% stenosis = PSV > 125 cm/sec, marked spectral
broadening and turbulence, severe plaque formation, and end
diastolic velocity elevated > 140cm/second
occlusion

76. Ocluzie ACI dr.
Stenoza contra-laterala
stg

77. Arterita Takayasu

78. Algoritm de managemnet al
stenozei carotidiene
American Heart Association & National Stroke Association

79. +
=

80. Relatia Stenoza /AIT-AVC
Lez carotidiene – deficit motor
Stenoza >60% - AIT/AVC
Frecventa stenozei carotidiene (>60%), masurata
planimetric prin ultrasonografie, la un lot de 197
pacienti spitalizati pentru AVC ischemic
Andritoiu A-2009

81. Riscul major al stenozei
carotidiene


Infarct cerebral (stroke) homolateral
pentru stenoza simptomatica
Deces de cauza cardiaca pentru
stenoza asimptomatica

82. OCLUZIA CAROTIDIANA

83. Ocluzie de ACI
(angiografie standard)

84. Colateralele din ocluzia ACI
Rutgers DR et al. Stroke 2000
Tipurile hemodinamice
intra-orbitare @ ocluzia ACI
n
Yamamoto T- Br J Ophthalmol 2004

85. Ocluzie ACI - CEUS

86. Manifestari alegodermitice dupa
administrarea de SonoVue, la un pacient in
varsta de 40 ani, cu teren atopic (alergie la
Penicilina). Reactia alergica s-a manifestat
tardiv (la peste 8 ore de la injectare) cu
elemente cutanate de tip urticarian, insotite de
prurit intens, tumefactia extremitatilor si
fotosensibilizare, ce s-au remis lent dupa
administrare de cortizon si antihistaminice
(colectia Dr. Andritoiu A)

87. Ligatura ACI

88. Ligatura ACE

89. Preocluzia ACI
FFF utile! Examinarea ACI distala / trans-orala

90. Falsa ocluzie

91. A oftalmica

92. ACM homolaterala

93. Debitul cerebral
Q = TAV x A
Q cer = Q ACI dr + Q ACI stg + Q AV dr + Q AV stg
Varsta (ani)
20-39
40-59
60-85
Q cerebral (mL/min)
727+/-102
656+/-121
603+/-106
Scheel P - Stroke 2000

94. QCG in stenoza
carotidiana
QCG (mL/min)
532+/-89
Stenoza
asimptomatica
224+/-89
Stenoza
simptomatica
Lam WWM - J Ultrasound Med 2003

95. Angioplastia
vs
Endarterectomia

96. Endarterectomia

97. US intra-operatorie

98. Stenturi carotidiene

99. Parametrii spectrali ai
stentului carotidian
PSV (cm/ s)
77+ / -4 90+ / -4
EDV (cm/ s)
25+ / -2 26+ / -2
86+ / -5
24+ / -2
92+ / -6
70+ / -3
24+ / -2
17+ / -1
Kupinski AM. J Vasc Ultrasound 2004

100. Restenoza post
endarterectomie
Restenoza post
stentare

101. Limitele cut-off propuse
pentru restenoza intrastent
Restenoza
PSV (cm/s)
ACI/ACC
50-69%
240
2.45
>70%
450
4.3
Chi Y-W - Catheterization and Cardiovascular Interventions 2007

102. Rezultatele terapiei
hipolipemiante in regresia
ATS

103. Reducerea LDL Col
CIMT
Regresia

104. METEOR
Modificarea IMT maxim la cele 12 nivele din
carotide (Rosuvastatin vs placebo)
Placebo
+0,0131 mm/an
(n=252)
+0,02
P<0,0001
(CRESTOR vs. placebo)
1
0,00
Rosuvastatin 40 mg
-0,0014 mm/an
(n=624)
2
Timp
(ani)
P=NS
(CRESTOR vs. curba zero)
Regresie
+0,01
-0,01
Progresie
Modificarea IMT la cele 12
nivele din carotide (mm)
+0,03
Placebo; Modificarea CIMT (95% CI)
Crouse JR, et al. JAMA 2007;297;12:1344-53
Rosuvastatin 40 mg; Modificarea CIMT (95%
CI)

105. Reducerea volumului placii sub terapia
cu Atorvastatin 80 mg/zi – evaluare la 3 luni
Ainsworth CD - Stroke 2005

106. Studii de fiziologie



Complianta
Distensibilitatea
Modulul de
elasticitate
Haluska et al. Cardiovascular Ultrasound 2007

107. Distensibilitatea ACI
Mancia G et al. Hypertension 2001

108. Cinetica peretelui
carotidian
si a placii (AWM)

TDI
Ramnarine et al. Cardiovascular Ultrasound 2003

109. Ramnarine et al. Cardiovascular Ultrasound 2003

110. PWV
Calabia et al. Cardiovascular Ultrasound 2011

111. Message take home
ABC-ul US carotidiene
A = anatomie
Identificarea vaselor este corecta?
Cat de bine este vizualizata bifurcatia ?
B = B-mode
Cauta placile pe axul ACC, ACI (omogene/heterogene)
C = Color
Se vizualizeaza stenoza?
Stenoza <60% se estimeaza planimetric!
D = Doppler spectral
Velocitatile ACI sunt
planimetrica a stenozei?
concordante
cu
estimarea